After long weeks in intensive care units — breathing through ventilators and fed through tubes, caught in a constant battle between life and death — some COVID-19 patients are fortunate enough to turn a corner.
But surviving the worst of it is only the beginning of recovery. Now, as state statistics show hospitalizations in Massachusetts beginning to descend, and intensive care units prepare to transfer thousands of those hospitalized, some worry that the lesser-known facilities where patients can slowly recover will soon be overwhelmed.
Long-term acute care facilities, or LTACs as they are known, play a crucial role in restoring severely ill patients’ health and relieving pressure on hospitals’ critical care units. They offer a range of therapeutic services and allow patients to fully recover in a less hectic environment, one designed to rehabilitate people who are stable enough to leave the hospital but still in too critical a state to be transferred to a skilled nursing or rehabilitation center. But there are only about a dozen such facilities across the state, and the few beds they have are filling up fast.
“Before the pandemic, LTAC beds were a hot commodity as it was, and now that has just been magnified probably by 1,000,” said Tony Fiscale, a case manager at the University of Massachusetts Memorial Medical Center in Worcester.
Fiscale said he is worried that he’ll soon have no place to send the many patients who are nearly ready to leave the hospital, but nowhere close to returning home. “It’s almost like the pot is ready to boil.”
There is no clear picture of how many recovery beds are available across the state. The Massachusetts Department of Public Health does not release long-term acute care capacity or bed availability as part of its daily COVID-19 dashboard and hospital census. In response to questions about capacity in the facilities, a department spokeswoman shared a memo with the Globe dated May 11 that counted 152 beds across the state for patients discharged from general hospitals. But not all of those beds were in long-term acute care facilities, which are uniquely equipped to handle intensive rehabilitation. And not all of the listed facilities accept COVID-19 patients.
Even if all the beds identified by the state were unoccupied and available to COVID-19 patients in need of continued acute care, it would probably not be enough. As of Friday, there were 2,323 patients hospitalized with COVID-19 in Massachusetts. If even 6 percent go on to require long-term acute care — a process that could last weeks — facilities could easily be overwhelmed.
“These are the sickest of the sick, and they survived,” said AnnMarie Rousseau, director of care coordination at UMass Memorial. “Now how are we going to restart the rehab process? If there’s a shortage, what’s our next step?”
A backlog at long-term acute care hospitals could ripple through the entire health care system.
“If we don’t lower our census [in acute care hospitals] by moving people to the appropriate level of care ... we’ll be very limited in our ability to take in a new wave” of COVID-19 patients, said Dr. Andrew Karson, chief medical officer at UMass Memorial. "And that’ll stretch us again to our limits.”
The shortage is looming especially large in parts of the state with few long-term acute care hospitals. Vibra Hospital of Western Massachusetts is the only such facility in the Worcester area that is accepting patients with COVID-19.
Karson is aware that the numbers are stacked against him, his staff, and his patients. His team anticipates that about 40 of its COVID-19 patients will need long-term acute care. Around one-third of those are ready for transfer now. But Vibra only has five beds in its COVID unit.
“Health care was not ready for this number of critically ill patients that have long-term acute needs,” Karson said. “It’s really swamping our already limited system.”
A shortage of beds also costs patients access to specialized care.
“What we do is different than what happens in acute care hospitals,” said David Storto, president of Partners Continuing Care and Spaulding Rehabilitation Network. “What we offer that general hospitals don’t have is that range of therapy services that improves people’s function. That allows people to be able to perform their activities of daily living.”
Many recovering COVID-19 patients need to be weaned off of ventilators and slowly reintroduced to eating on their own. Some also require speech therapy, pulmonary therapy, and dialysis.
This is exactly the type of care that long-term acute care hospitals specialize in. But prior to the pandemic, policymakers and insurers were less convinced of the critical role such facilities play.
“Historically, we’ve almost been trying to downsize long-term care hospitals,” explained David Grabowski, a professor of health care policy at Harvard Medical School. “There’s been a lot of questions over the last 10, 15 years about what’s their role in the health care system.”
Medicare lists just over 370 long-term acute care hospitals in the United States. Compared to the country’s thousands of nursing homes and skilled nursing centers, these facilities have been relegated to a small corner of the post-acute care world, and an even smaller corner of the massive health care system.
But COVID-19 has reminded the world of the importance of facilities that occupy the middle ground of the critical care landscape.
“In a pandemic, you really do need that kind of intensive care,” said Grabowski, who coauthored a paper advocating for the importance of long-term acute care hospitals. “For years, we said, ‘Why do we need long-term care hospitals?’ And all of a sudden with COVID, we’re saying, ‘Why don’t we have more long-term care hospitals?’ ”
Mary Moscato, president of Hebrew SeniorLife Health Care Services and Hebrew Rehabilitation Center in Boston, also has noticed a shift.
“This time period has certainly brought to light the need for LTACs during a pandemic that has major respiratory and cardiac issues,” she said, noting that federal admissions criteria have relaxed during the coronavirus outbreak.
Still, recent changes have done little to fix a lack of beds caused by years of sidelining.
Though UMass Memorial has not yet had patients turned away from long-term acute care facilities, it is already planning for what will happen when the region’s few beds for COVID-19 patients are inevitably filled. Karson said administrators have considered what it would take to create a long-term facility within the larger general hospital, a remote possibility the hospital hopes will not become reality.
For now, hospital administrators are left juggling a growing list of patients in need of transfer with a severely limited number of beds.
“We work very closely every single day, multiple times through multiple points of contact with the referring hospitals,” said Bob McCall, senior vice president of network development and inpatient rehabilitation services at Spaulding Rehabilitation Network. “We try to anticipate how we best prepare the units and the numbers of beds.”
According to Moscato, of Hebrew SeniorLife, long-term acute care facilities have been able to coordinate with acute care hospitals outside of their usual networks and collaborate to relieve demand in the most desperate parts of the state.
“We have gotten together as post-acute hospitals, rehabilitation, and LTACs to determine bed availability, equipment availability, and where some of those patient bottlenecks may be,” she said. “And to see if we as a group can assist the state and give acute care hospitals some of that relief.”
In the meantime, patients are waiting at the precipice of their journey to recovery.